Kenya: Cervical cancer vaccine offers hope but challenges persist

February 18, 2014

Life is rough for women with cervical cancer in Kenya. Some of those attending the country’s only public treatment facility sleep on benches and concrete floors outside the hospital to save money for their treatment. Others never make it to the capital for assistance because they cannot afford the bus journey. Now, a vaccination programme has been rolled out, offering hope for future generations.

“Cervical cancer vaccine now available for girls in primary school free of charge!” reads the turquoise poster outside the office of Christina Mavindu, senior nursing officer at the Kitui district hospital. Mavindu is two-thirds of the way through implementing Kenya’s first public cervical cancer vaccination campaign in Kitui county. The third and final jabs will be administered in the next few weeks.

The campaign has been challenging. The number of children wanting the vaccine has exceeded the doses available and, at a cost of more than $50 per vaccine, many people have been unable to pay for it privately. “It should be for everybody,” says Mavindu. Gavi (Global Alliance for Vaccines and Immunisation) supported the trial to enable Kenya to demonstrate that it has the necessary infrastructure and capacity to vaccinate nine- to 13-year-olds on a national scale.

Vaccination is needed urgently; cervical cancer is a growing cause of morbidity among women in Africa, and a rising concern. The disease is nearly six times more prevalent in Kenya than in western Europe, according to WHO data. It is also the cancer that kills most women in Kenya, whose neighbour Rwanda became the first low-income African country to achieve nationwide access to the vaccine.

The treatment for cervical cancer is inadequate: nearly half of the women who were being treated in Kenya “disappeared” from their programmes, according to the results of a recent survey published in the journal Plos One of patients at the only public cancer treatment centre. “Most likely they could not afford treatment,” says Dr Ian Hampson, head of gynaecological oncology at the University of Manchester, who oversaw the research. Just 7% of women received “optimal treatment”, while 41% dropped out.

(Pic: Reuters)

From screening to diagnosis and treatment, best practice in Kenya is impeded at every stage. Beatrice Ngomo, a nurse in Kitui district hospital’s maternal and child health clinic, has a hard time persuading women to get screened. Many cannot afford medical care so do not want to know if they are ill, she explains. Others do not like invasive procedures, she says, and are scared.

Even when a woman starts experiencing symptoms, she will often not seek treatment, Ngomo explains. Some women think cervical cancer is a result of witchcraft so they prefer to see traditional medical practitioners. “They lose a lot of time while they’re doing that,” Ngomo says. Or they go to witchdoctors because they are more affordable than modern medical care. As a result, 80% of cases at the hospital are late stage cancer, according to doctors’ estimates.

Ngomo has diagnosed two women with cervical cancer this year. She recalls that at first the women assumed that the cancer would kill them. Ngomo told them that treatment was poshsible and referred them to the Kenyatta national hospital in Nairobi. “But there the problems really start,” she says. In Kitui, most people are farmers and the average daily wage is less than $2. Women cannot afford to travel to the capital, let alone buy high-cost drugs, she adds. Sometimes they reappear at the hospital in Kitui months after referral, having never made it to Nairobi.

The next problem is that the waiting time for a first appointment at Kenyatta national hospital can be up to six months, according to Dr Orora Maranga, who conducted the Manchester research and is now practising in Kenya. “The cancer is not waiting,” he says. In six months, it can grow from stage two to stage four, drastically reducing the chance of survival.

Once patients receive an appointment, they are faced with the costs of treatment. Elizabeth Mumbua Njeru, 35, sits on a step outside the casualty ward hugging her handbag to her chest. Njeru has a cancerous tumour in her cervix and is two months into a course of radiation and chemotherapy. Njeru, from Embu, 120km to the north, is unable to afford accommodation in the capital. She has been a resident of the casualty ward for two months and is sometimes forced to sleep on this outside. But she is determined not to become another women who “disappears”.

Her malnourished body is struggling to cope with the treatment regime. Her nails have turned brown, she suffers from nausea and diarrhoea, and her immune system has been severely compromised by daily injections of cytotoxins. Njeru knows the emergency department is no place for her; it is a hub of infectious diseases which she might catch at any moment. But she has no option.

Maranga’s study found that just 7% of patients at Kenyatta national hospital were receiving optimum treatment. But it is not just the cost that prevents them getting the correct treatment. The hospital lacks one crucial piece of equipment: the brachytherapy machine.

As Njeru sits in the hospital canteen enjoying a rare plate of fried chicken, she is joined by her friend, Rhonda Waeni Ndundua, who also has cervical cancer. Ndundua has also spent two months sleeping rough in the hospital grounds. Rhonda has received good news – she has been discharged. Scribbled on her patient records was one word: “brachytherapy”. Rhonda is free to go home, but has to return to see the doctor in two months. Then, she will be told that she needs to have brachytherapy, radiotherapy delivered internally, in order to receive the recommended treatment.

Hampson describes Kenyatta national hospital’s brachytherapy unit as having been “in a state of disrepair for several years”. Patients like Ndundua must travel to either Dar-es-Salaam in Tanzania, or to Kampala in Uganda. There, they pay 30 000 Kenyan shillings ($360) for the brachytherapy; food, accommodation and transport are additional.

This may go some way towards explaining why just 7% of women in the Manchester study received optimal treatment. Hampson suggests there is no money, and therefore no political will from the government to repair the brachytherapy machine.